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psnet.ahrq.gov/node/39116/psn-pdf
April 30, 2014 - embolism and drug reactions or overdose, with the errors occurring
most frequently in the testing phase
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psnet.ahrq.gov/node/45533/psn-pdf
November 02, 2016 - The next
phase involved giving health systems financial incentives to report their data on harm-free
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psnet.ahrq.gov/issue/pharmacist-led-educational-interventions-provided-healthcare-providers-reduce-medication
October 14, 2020 - The phase, educational strategy , patient population, and audience varied across studies; however most
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psnet.ahrq.gov/issue/implementation-health-information-technology-safety-classification-system-veterans-health
August 04, 2021 - After the retrospective phase, classification of reports was integrated into weekly meetings.
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psnet.ahrq.gov/issue/crisis-preparedness-systems-based-framework-avoiding-harm-surgery
September 14, 2022 - An earlier study by the authors describes the second phase in managing crisis: crisis recovery .
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psnet.ahrq.gov/issue/what-i-wish-id-known-how-experienced-physician-managers-diagnose-treat-and-prevent-disruptive
September 23, 2020 - The authors stress maintaining curiosity during the “diagnostic” phase, careful consideration of “treatment
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psnet.ahrq.gov/issue/seeing-through-google-glass-using-innovative-technology-improve-medication-safety-behaviors
September 15, 2021 - 2014
Characteristics of medication errors made by students during the administration phase
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psnet.ahrq.gov/issue/patterns-medication-incidents-10-yr-experience-cross-national-anaesthesia-incident-reporting
January 15, 2025 - Of the 1970 MRE identified, the highest number (42%) occurred during the administration phase, and a
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psnet.ahrq.gov/issue/reducing-continuous-intravenous-medication-errors-intensive-care-unit
September 27, 2016 - This commentary describes the results of a two-phase initiative intended to reduce errors related to
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psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
October 04, 2023 - During the first phase, team members are asked whether there is a risk of blood loss greater than 500 … During the second communication phase, the surgeon is asked to confirm the anticipated blood loss and … all checklist points are thoroughly discussed, and concerns addressed, before proceeding to the next phase
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psnet.ahrq.gov/node/46352/psn-pdf
October 15, 2018 - Optimal Resources for Surgical Quality and Safety.
October 15, 2018
Hoyt DB, Ko CY, eds. Chicago, IL: American College of Surgeons; 2017. ISBN: 9780996826242.
https://psnet.ahrq.gov/issue/optimal-resources-surgical-quality-and-safety
Surgery is complex and involves a wide range of possibilities for error that can r…
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psnet.ahrq.gov/perspective/long-term-care-and-response-covid-19
October 28, 2020 - We are in the eighth year now, and the second phase of the work. … In the first phase, we worked with 16 nursing facilities in Missouri with high re-hospitalization numbers … The second phase of the initiative introduces a billing component. … LP : We're actually writing an article right now for the results of the second phase of the Initiative … We have something like 3000 root cause analysis tools in Phase 1 and 3500 in Phase 2.
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psnet.ahrq.gov/perspective/conversation-charles-crecelius-md-phd-cmd-and-lori-l-popejoy-phd-rn-faan
October 28, 2020 - We are in the eighth year now, and the second phase of the work. … In the first phase, we worked with 16 nursing facilities in Missouri with high re-hospitalization numbers … The second phase of the initiative introduces a billing component. … LP : We're actually writing an article right now for the results of the second phase of the Initiative … We have something like 3000 root cause analysis tools in Phase 1 and 3500 in Phase 2.
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psnet.ahrq.gov/issue/effect-smartphone-based-application-learning-nursing-students-performance-preventing
June 14, 2023 - 2010
Characteristics of medication errors made by students during the administration phase
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psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
October 30, 2024 - During the upfront planning phase, roughly 8 to 10 staff participated in the core patient identification … During the upfront planning phase, roughly 8 to 10 staff participated in the core patient identification
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psnet.ahrq.gov/node/40747/psn-pdf
September 07, 2011 - Misdiagnosis: analysis based on case record review with
proposals aimed to improve diagnostic processes.
September 7, 2011
Neale G, Hogan H, Sevdalis N. Misdiagnosis: analysis based on case record review with proposals aimed
to improve diagnostic processes. Clin Med (Lond). 2011;11(4):317-321.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/43795/psn-pdf
December 17, 2014 - Systematic Systems Analysis: A Practical Approach to
Patient Safety Reviews.
December 17, 2014
Duchscherer C, Davies JM. Calgary, Alberta, Canada: Health Quality Council of Alberta; 2012.
https://psnet.ahrq.gov/issue/systematic-systems-analysis-practical-approach-patient-safety-reviews
Drawing from human factors a…
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psnet.ahrq.gov/issue/harmful-medication-errors-involving-unfractionated-and-low-molecular-weight-heparin-three
October 23, 2018 - 300,000 medication events reported, approximately 4% involved heparin products, with the administration phase
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psnet.ahrq.gov/issue/special-issue-medication-safety
June 26, 2019 - Effect of a pharmacist-led multicomponent intervention focusing on the medication monitoring phase
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psnet.ahrq.gov/issue/beyond-patient-safety-flatland
September 04, 2024 - July 15, 2020
Response of practicing chiropractors during the early phase of the COVID